# COMAR Title 10 — Maryland Department of Health

## Subtitle 09 — Medical Care Programs

### Chapter 55 — Physician Assistants

**Authority:** Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland

**Administrative History:** Effective date: May 11, 2015 (42:9 Md. R. 647)

**Administrative History:** Regulation .03A amended effective July 10, 2023 (50:13 Md. R. 512)

**Administrative History:** Regulation .06 amended effective September 26, 2016 (43:19 Md. R. 1072)

**Administrative History:** Regulation .06G amended effective July 10, 2023 (50:13 Md. R. 512)

#### Regulation .01 Definitions.

*COMAR 10.09.55.01*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Advanced duties” means medical acts that require training and certification beyond the basic physician assistant education program.

  (2) “Board” means the State Board of Physicians.

  (3) “Delegation agreement” means a document that is executed by a licensed physician and a physician assistant containing the requirements of Health Occupation Article, §15-302, Annotated Code of Maryland, and COMAR 10.32.03.05.

  (4) “Department” means the Maryland Department of Health, the single State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

  (5) “Dispense” means to dispense starter dosages or drug samples.

  (6) “Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.

  (7) “Modification” means any change to the delegation agreement that governs the physician assistant’s performance of duties, including but not limited to practice location, scope of practice, change of supervising physician (primary or alternate), and prescriptive authority.

  (8) “Physician” means an individual who meets the licensure requirements and conditions of participation of COMAR 10.09.02.

  (9) “Physician assistant” means an individual who is licensed to practice medicine with physician supervision.

  (10) “Practice as a physician assistant” means the performance of medical acts that are:

    (a) Delegated by a supervising physician to a physician assistant;

    (b) Within the supervising physician’s scope of practice; and

    (c) Appropriate to the physician assistant’s education, training, and experience.

  (11) “Program” means the Maryland Medical Assistance Program.

  (12) “Provider” means a licensed physician assistant who, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of a provider number.

  (13) “Participant” means a person who is certified as eligible for, and is receiving, Medical Assistance benefits.

  (14) "Supervision” means the responsibility of the physician to exercise on-site supervision or to be able to provide immediate available direction for the physician assistants performing delegated medical acts, and includes:

    (a) Oversight of the physician assistant and acceptance of direct responsibility for the patient services and care rendered by the physician assistant;

    (b) Continuous availability to the physician assistant either in person, by telephone, by electronic means, or by some other form of telecommunication; and

    (c) Designation of one or more alternate supervising physicians.

#### Regulation .02 License and Certification Requirements.

*COMAR 10.09.55.02*

A. The provider shall meet all license requirements as set forth in COMAR 10.09.36.02.

B. A physician assistant applying for provider status shall:

  (1) Be licensed to practice as a physician assistant in Maryland or in the state or jurisdiction in which the service is provided;

  (2) Be in compliance with requirements set forth in COMAR 10.32.03;

  (3) If practicing in Maryland, have a delegation agreement with a supervising physician that outlines the physician assistant’s duties within the medical practice or facility which has been filed with and approved by the Board of Physicians; and

  (4) If practicing in Maryland, have a delegation agreement with a supervising physician that documents the specialized training, education, and experience of the physician assistant for performing advanced duties.

C. A physician having a written agreement to supervise a physician assistant shall:

  (1) Be licensed to practice medicine in the state in which the physician assistant is providing services;

  (2) Delegate only medical acts that are within the scope of the practice of the physician and are suitable to be performed by the physician assistant, taking into account the physician assistant’s education, training, and level of competence;

  (3) Accept Program reimbursement as payment in full for services provided;

  (4) Establish and review drug and other medical guidelines with the physician assistant;

  (5) Participate with the physician assistant in reviewing and discussing medical diagnoses and the therapeutic and corrective measures employed in the practice setting;

  (6) Be available for consultation in person, by telephone, electronic means, or by some other form of telecommunication; and

  (7) Designate an alternate supervising physician if the physician identified in the delegation agreement temporarily becomes unavailable.

D. For hospitals, correctional facilities, detention centers, or public health facilities, the primary supervising physician shall keep an ongoing list of all approved alternate supervising physicians within the alternate supervising physicians’ scopes of practice, with each alternate supervising physician’s signature and date.

#### Regulation .03 Conditions for Participation.

*COMAR 10.09.55.03*

A. A physician assistant shall:

  (1) Meet all general provider requirements set forth in COMAR 10.09.36; and

  (2) If delivering services via telehealth, comply with COMAR 10.09.49 and any subregulatory guidance issued by the Department.

B. A physician assistant shall:

  (1) Have a written and executed delegation agreement with a licensed physician approved by the Board, or as required by the state in which services are provided; and

  (2) If the primary supervising physician delegates the prescribing of controlled dangerous substances to a physician assistant, if required by applicable law, the physician assistant shall:

    (a) Obtain a Maryland Controlled Dangerous Substance (MCDS) license from the Maryland Division of Drug Control; and

    (b) After obtaining an MCDS license:

      (i) Register with the Drug Enforcement Administration (DEA); and

      (ii) Obtain a license from the DEA.

C. To participate as a provider, the physician assistant shall submit to the Program a copy of the provider's:

  (1) Current approved delegation agreement; and

  (2) Current license to practice in the state in which services are provided.

D. Modification of Delegation Agreement.

  (1) If the provider's approved written delegation agreement with the physician is modified or terminated by either party, the physician assistant and supervising physician shall notify the Program within 5 days in writing.

  (2) If the delegation agreement is modified, the physician assistant and the supervising physician shall submit to the Program a copy of the modified or new written agreement.

  (3) If the duties of the physician assistant are limited, reduced, or result in other changes of employment that might be grounds for disciplinary actions under Health Occupations Article, §15-314, Annotated Code of Maryland, the supervising physician, hospital, alternative health care system, or employer shall notify the Program immediately or within 5 days in writing.

E. A physician assistant may practice in Maryland:

  (1) Only in accordance with the delegation agreement approved by the Board; or

  (2) If out-of-State, only in accordance with the scope of practice allowed by the licensing authority in the state in which services are provided.

#### Regulation .04 Covered Services.

*COMAR 10.09.55.04*

A. The Program covers medically necessary services rendered to participants in accordance with:

  (1) The functions allowed under:

    (a) The Physician Assistant’s Practice Act;

    (b) COMAR 10.32.03; and

    (c) The physician assistant’s written delegation agreement with a physician; or

  (2) If out-of-State, those functions authorized in the state in which the services are provided.

B. The services in §A of this regulation shall be described in the participant's medical record in sufficient detail to support the invoice submitted for those services.

#### Regulation .05 Limitations.

*COMAR 10.09.55.05*

The Program does not cover the following under these regulations:

A. Services not encompassed by the physician assistant’s written delegation agreement with the physician, if required by the state in which services are provided;

B. Services not medically necessary;

C. Services prohibited by the Board;

D. Services prohibited in the state in which services are provided;

E. Physician assistant services included as part of the cost of an inpatient facility, hospital outpatient department, or freestanding clinic;

F. Visits by or to the physician assistant solely for the purpose of the following:

  (1) Prescription, drug, or food supplement pickup;

  (2) Recording of an electrocardiogram;

  (3) Ascertaining the patient's weight;

  (4) Interpretation of laboratory tests or panels; or

  (5) Prescribing or administering oral medications;

G. Drugs and supplies which are acquired by the licensed and certified physician assistant at no cost;

H. Injections and visits solely for the administration of injections, unless medical necessity and the patient's inability to take appropriate oral medications are documented in the patient's medical record;

I. More than one visit per day per participant unless adequately documented as an emergency situation;

J. Services paid under the free-standing dialysis program described in COMAR 10.09.22;

K. Physician assistant billings for those laboratory or X-ray services performed by another facility, which shall bill the Program directly;

L. Immunizations required for travel outside the continental United States;

M. Acupuncture;

N. Hypnosis;

O. Travel expenses;

P. Prescriptions and injections for central nervous system stimulants and anoretic agents when used for weight control;

Q. Investigational or experimental drugs and procedures;

R. Services denied by Medicare as not medically justified; and

S. Services for which the patient specifically requests to see a physician.

#### Regulation .06 Payment Procedures.

*COMAR 10.09.55.06*

A. The provider shall submit the request for payment in the format designated by the Department.

B. The Department reserves the right to return to the provider, before payment, all invoices not properly signed, completed, and accompanied by any properly completed forms required by the Department.

C. The provider shall charge the Program the provider's customary charge to the general public for similar services and charge the provider's acquisition cost for injectable drugs or dispensed medical supplies. If the service is free to individuals not covered by Medicaid:

  (1) The provider:

    (a) May charge the Program; and

    (b) Shall be reimbursed in accordance with §D of this regulation; and

  (2) The provider's reimbursement is not limited to the provider's customary charge.

D. The Department shall reimburse the physician assistant for covered services at the lesser of:

  (1) The provider's customary charge unless the service is free to individuals not covered by Medicaid; or

  (2) The maximum rates according to COMAR 10.09.02.07E.

E. Payments on Medicare claims are authorized, if:

  (1) Services are covered by the Program;

  (2) The provider accepts Medicare assignments;

  (3) Medicare makes direct payment to the provider;

  (4) Medicare has determined that services were medically justified; and

  (5) Initial billing is made directly to Medicare according to Medicare guidelines.

F. The Department shall make supplemental payments on Medicare claims subject to the following provisions:

  (1) Deductible insurance shall be paid in full; and

  (2) Coinsurance shall be paid at the lesser of:

    (a) 100 percent of the coinsurance amount; or

    (b) The balance remaining after the Medicare payment is subtracted from the Medicaid rate.

G. The provider may not bill the Program for:

  (1) Completion of forms and reports;

  (2) Broken or missed appointments;

  (3) Professional services rendered by mail; and

  (4) Providing a copy of a participant's medical record when requested by another licensed provider on behalf of the participant.

H. The Program may not make direct payment to participants.

I. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.

J. Physician assistants who are employed by or under contract to any physician, clinic, or hospital may not bill for any service for which reimbursement is sought by the physician, clinic, or hospital.

#### Regulation .07 Recovery and Reimbursement.

*COMAR 10.09.55.07*

Recovery and reimbursement are as set forth in COMAR 10.09.36.07.

#### Regulation .08 Cause for Suspension or Removal and Imposition of Sanctions.

*COMAR 10.09.55.08*

Cause for suspension or removal and imposition of sanctions is as set forth in COMAR 10.09.36.08.

#### Regulation .09 Appeal Procedures.

*COMAR 10.09.55.09*

Providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09.

#### Regulation .10 Interpretive Regulation.

*COMAR 10.09.55.10*

State regulations shall be interpreted in conformity with COMAR 10.09.36.10.